Saturday, January 27, 2007

Choose your own adventure

Does anybody remember those ‘Choose your own adventure’ children’s books that were popular about 20 years ago? You read part of a story and then had to make a decision about what the character did next. Depending on your decision the story was continued in line with your choice on a different page. I always seemed to choose the option that led to death but let’s forget about that now.

Here’s the new NHS version

Mrs Smith is a 63 year old widow who started feeling dizzy and a bit ‘funny’ one morning. She sat down for a bit and had a cup of tea but it didn’t go away. She told herself to ‘pull yourself together’ but it still didn’t go away. Being a stoic type she didn’t want to bother her doctor and she didn’t want to miss her friend who was coming over later. When Mrs Smith’s friend arrived she thought Mrs Smith looked a bit peaky and persuaded her to:

1. Mrs Smith felt embarrassed about being in A+E when she didn’t really think it was anything. When the triage nurse saw her she explained that she just had a bit of a dizzy feeling and it was nothing really. She didn’t have any pain or feel short of breath. The nurse did some observations and noticed that Mrs Smith’s heart rate was only 30 per minute. The nurse took Mrs Smith through to another room and called a doctor over, while connecting Mrs Smith up to a heart monitor and giving her some oxygen. The doctor saw Mrs Smith straight away and she was admitted to hospital with a complete (third degree) heart block. The next morning she had a pacemaker put in.

2. ‘I’m sorry to bother you,’ Mrs Smith said to her GP, and explained about the dizzy feeling. The GP asked if she had any other problems and she said she’d had some heartburn the other night, which was odd because she hadn’t eaten tomatoes which usually brought it on. The GP took her pulse and blood pressure and then told Mrs Smith that her heart rate was dangerously low and that she would have to go to hospital in an ambulance which was rather a shock to her! The next morning she had a pacemaker put in.

3. Mrs Smith had heard that NHS Direct was now available online and decided her broadband connection would probably be quicker than the phone: ‘They might put me on hold with some dreadful music’ she said. On the NHS Direct website she found ‘dizziness in adults’ in the A-Z of symptoms. She didn’t have any pain anywhere, feel feverish (she didn’t have a thermometer), feel breathless, she didn’t think she was going to faint, have any ringing in her ears or any of the other things they asked. NHS Direct told her she should stay at home. She made another cup of tea.

What I’m trying to illustrate is not that NHS Direct is useless (although personally I think it is an unnecessary waste of money) but that if you are seen as an emergency in hospital you are being seen by somebody (hopefully a doctor!) who is experienced in seeing emergency patients and has access to a second opinion from doctors who are more senior and/or in different specialties, and has rapid access to blood tests, x-rays and other investigations to help them decide what is wrong and how best to treat you.

If you go to your GP as an emergency you are being seen by an experienced doctor who can examine you, perform some basic tests and decide what to do next. The GPs job in this situation is more difficult as he or she doesn’t have immediate access to specialists and many other tests like the A+E doctor does.

If you phone a helpline you are talking to somebody who, whatever their level of clinical skill, is unable to even see you, let alone examine you and has to rely solely on what you say and the protocol in front of them. They cannot see your lips turn blue as you stoically claim to be ‘not too bad’ or see you sitting comfortably while claiming to be ‘doubled up in agony’. This is why telephone consultations/telephone triage should be done (if at all) by the most experienced, knowledgeable and qualified people available.

Phone advice was one of the most terrifying things to do as a junior doctor. I usually advised people to come in and be seen, as did my seniors - not because we wanted the extra work but because it was far safer. Protocols rely on patients and diseases being relatively 'standardised' but once you've seen a few real patients you soon realise there are plenty that don't fit the 'standard'.

P.S. I deleted that out of place comment on the post below Dr Grumble, hope that's OK.

a) the website protocols for NHSD are entirely different to the phone protocols.

b)anyone presenting with any degree of cyanosis gets to speak to a nurse immediately with NHS Direct (don't know about NHS 24 as it's a different service) It's the second qUestion anyone calling the service is asked, after checking the patient is actually conscious

x) The organisation being sued is NHS 24, not NHS Direct. The service is similar, but assessment is less stringent and therefore more prone to error.

Brilliant post, Dr K, simply brilliant. There's something fundamentally flawed about NHS Direct, and Dr Grumble (in his post that linked here) said it very well when he stressed that you can't protocolise medicine like this.

I agree with not blaming the operators of NHS Direct (Or NHS 24) but rather the politicos who put the system in place. They should have IQ tests for the goons whose job it is to dream up schemes like this.

Oh, and I used to be addicted to those Choose Your Own Adventure books. Inpired analogy, that :)

I did think that NHS 24 was simply the Scottish version of NHS Direct, thanks for pointing out the difference, anonymous. In the story my patient didn't have cyanosis (neither did the real-life patient I once saw who was walking around with the same condition, it was quite frightening), and I'd be appalled if somebody who did have didn't get some medical help from either service.

I still think that protocolised telephone consultations like these are inherently dangerous

I'm an ex-medical SHO with a chronic respiratory condition. In a good light, with a large mirror, I cannot reliably determine whether I am cyanosed, when I am unwell. And I have seen hundreds of cyanosed patients.

When half-blind, half-deaf, confused, 80 year old Mrs Smith, peering into the mirror of her compact under her 40 watt light bulb, tells the operator at NHS Direct that her lips are not blue, how useful is that information, really?

My own experience of this "service" is not good. I routinely try to get patients to bypass this system and call us Ambo's direct. At least we can see them and do stuff before battering them up to the docs.

Invariably it is the older people, the ones the NHS was set up for, who are reluctant to "cause a fuss".

I am an Ophthalmologist and as such we get tons of expectant referrrals over the phone. Quite reasonably, not many doctors know very much about eyes and so they get on the phone and ask us.

After 3 years of taking these calls, all (mostly?!) from sensible doctors, I have realised that there is just no way to make a differential diagnosis from a phone call.

All you can do is triage and then that triage is pretty rough and basic splitting into 1- need to see tonight and 2 - need to see tomorrow.

The next bit might sound a little arrogant but....

If I can't triage better than that over the phone, when I am an experienced specialist doctor speaking to other doctors, then why should a nurse speaking over the phone to a scared and ill patient be able to?

I too am impressed by the 'Choose your own adventure' analogy - may we borrow it from time to time?

Also, could you ask them to reduce the number of pages that end with 'call 999 for an ambulance' for no rational reason,as all our ambulances are stacked up outside Accident and Emergency.

It wouldn't be a big problem, only they aren't allowed to unload until 3.5hours before someone can see them, regardless of whether the patient is well or dying - otherwise they might break the sacred 4 hour rule, so they are there for ages - which means ill peiple needing 999 transport to hospital get a man on a motorbike.

Personal experience of telephone triage leads me to think it is positively dangerous. Called up with breathing difficulties - diagnosis on the phone - panic attack - actual diagnosis - pulmonary embolism!!! If I didn't have a very stubborn flatmate I'd probably be dead! This was despite saying I was turning blue... The nurse got stuck in some protocol somewhere... and the fact that I'm 27 didn't help. It was pretty bloody scary. I didn't call an ambulance initially because I didn't want to waste resources and latterly because I wasn't with it enough to realise I should.

I'm not blaming the staff - just the system that they have to follow that took them off in the wrong direction.

About Me

Dr K is a junior doctor specialising in histopathology. When she tells people she is a pathologist they sometimes have some strange reactions. In fact very few people understand what pathologists do except other pathologists. Dr K is sick of people thinking she is a psychopath and wants to sort out some of these misconceptions, as well as having a good whinge about medicine, the universe and pathology.